Endometriosis is a disorder in which endometrium (tissue that normally lines the inside of uterus) grows outside uterus. It is a very painful condition, most commonly involves ovaries, fallopian tubes, and the tissue lining the pelvis.

The displaced endometrial tissue continues to act as normal endometrium i.e

  • It thickens
  • It breaks down
  • And it bleeds with each menstrual cycle

As these displaced endometrial tissue has no way to exit from body, it becomes trapped. ENDOMETRIOMAS are cysts, formed when endometriosis involves the ovaries. Surrounding tissue becomes irritated and eventually developing bands of fibrous tissue (abnormal) that can cause pelvic tissues and organs to stick to each other.

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The lesions vary in size from a small black spot to a large cystic mass filled with blood. The fluid content of blood is absorbed and the dark coloured solid content gives appearance like chocolate material fills the cyst, commonly known as CHOCOLATE CYST.

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SITES OF ENDOMETRIOSIS:

  • PELVIC ORGANS: ovaries, oviducts, pouch of Douglas, uterosacral ligaments, broad ligaments.
  • GENITAL TRACT: vagina, cervix, episiotomy scars.
  • URINARY TRACT: surface of urinary bladder.
  • BOWEL: pelvic colon, rectum, may occur in appendix.
  • OTHERS: umbilicus, laparotomy scar etc.

SIGNS AND SYMPTOMS:

  1. Painful periods (dysmenorrhea), pelvic pain and cramping may begin before periods and extend several days after period.
  2. Pain with intercourse
  3. Painful bowel movements and painful urination during menstrual periods.
  4. Abnormal and heavy menstrual bleeding
  5. Infertility or subfertility
  6. Weight loss, bloating and excess fat on the hips and stomach regions.
  7. Other symptoms may include fatigue, diarrhea, nausea, some emotional mental conditions.

CAUSES OF ENDOMETRIOSIS:

  1. RETROGRADE MENSTRUATION: In this condition, menstrual blood containing endometrial cells flows back through fallopian tubes into the pelvic cavity instead of out of the body. These displaced cells stick to the pelvic walls and surface of pelvic organs, where they grow, thickens, and bleed just like the course of each menstrual cycle.
  2. TRANSFORMATION OF PERITONEAL CELLS
  3. EMBRYONIC CELL TRANSFORMATION: Hormones such as estrogen may transform embryonic cells into endometrial cell implants during puberty.
  4. SURGICAL SCAR IMPLANTATION: After hysterectomy or C-section, endometrial cells may attach to a surgical incision.
  5. ENDOMETRIAL CELL TRANSPORT: The blood vessels or lymphatic system may transport endometrial cells.
  6. IMMUNE SYSTEM DISORDER: Immune system disorder may make the body unable to recognize and destroy displaced endometrial tissue.

RISK FACTORS:

  • Delayed first pregnancy
  • Never giving birth
  • Early menarche
  • Late menopause
  • Short menstrual cycles
  • Heavy menstrual periods
  • Very high level of estrogen
  • Low BMI (body mass index)
  • One or more relatives (mother, siblings) with endometriosis.
  • Obstruction to the normal passage of menstrual flow out of the body.

COMPLICATIONS:

  • Infertility
  • Cancer

INVESTIGATIONS;

  • Vaginal and endocervical swabs
  • Laproscopy
  • Pelvic Ultrasound
  • Serum CA-125
  • CT scan & MRI

DIFFERENTIAL DIAGNOSIS:

Endometriosis is sometime mistaken for other conditions, like;

  1. PID (pelvic inflammatory disease)
  2. IBS (irritable bowel syndrome)
  3. Adenomyosis

TREATMENT:
MEDICAL TREATMENT:

NSAIDs like ibuprofen, naproxen etc are used as pain medications.

HORMONE THERAPY:

  • Oral contraceptive pills (pseudo-pregnancy)
  • Progestin therapy
  • Gestrinone
  • Aromatase inhibitors
  • Gonadotrophin-releasing hormone (Gn-RH) analogues

SURGICAL TREATMENT:

Surgical treatment is indicated in conditions like,

  • Endometriomas
  • Pelvic adhesions distorting the pelvic anatomy
  • Blocked fallopian tube

Surgical approach may be conservative or radical. CONSERVATIVE SURGERY mean that excision of endometriotic tissue while preserving reproductive capabilities (preserving uterus and ovaries). Conservative surgery along with hormone therapy is the best treatment option for the young patients.

RADICAL SURGERY involves excision of endometrial displaced tissues, hysterectomy (surgical removal of uterus), and bilateral oophorectomy (surgical removal of ovaries). It is the best treatment option for aged women, those who have completed their families.

LIFESTYLE CHANGES:

A low fat diet (vegetarian diet) may improves dysmenorrhea. There are suggestions that exercise may improve symptoms by improving blood flow to the pelvis.

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